Beschrijving:The pilot in command and copilot commenced duty in Cairns for the scheduled Cairns (CNS) - Lockhart River (IRG) - Bamaga (ABM) - Lockhart River (IRG) - Cairns (CNS) flight. The flight was operated by Transair but conducted on behalf of Aero-Tropics Air Services. Aero-Tropics would provide ground handling, pilot briefing facilities and marketing services. Transair provided the airplane and crew.The Metro 23 aircraft departed Cairns at 08:31. During the descent to Lockhart River on the northbound flight, the crew intended to perform a runway 30 RNAV (GNSS) approach. Late in the approach, the crew appropriately manoeuvred the aircraft to land on runway 12. The engines were shutdown at 09:50. The aircraft departed Lockhart River at 09:58 and arrived at Bamaga at 10:39. The aircraft was refuelled at Bamaga for the return flight to Cairns via Lockhart River to collect two passengers. The pilot in command commented to the ground agent prior to departing Bamaga that the weather was 'bad' at Lockhart River and it may not be possible to land there. The forecast conditions at the aerodrome included a broken10 cloud base 1,000 ft above the aerodrome for periods of up to 60 minutes. The aircraft departed Bamaga at 11:07 and climbed to the cruising altitude of FL170. Descent was commenced at 11:32. Three minutes later the copilot advised Brisbane ATC that the aircraft was on descent, passing 10,000 ft AMSL with an estimated time of arrival at Lockhart River of 11:38. At 11:39 the copilot broadcast on the CTAF (Common Traffic Advisory Frequency) that the crew was conducting the runway 12 RNAV (GNSS) approach, and that the aircraft was at the 'Whisky Golf' (LHRWG) waypoint and tracking for the 'Whisky India' (LHRWI) waypoint. At 11:41 the airplane was over the LHRWI intermediate fix and descent was recommenced at 4.8 NM from the LHRWF waypoint. This was 3.1 NM before the descent point specified on the approach chart for the 3.49 degree constant angle approach path to the missed approach point. After levelling briefly at 3000 feet 18 degrees of flaps were selected. The aircraft then commenced descent 1.4 NM before the final approach fix (FAF). This was 0.3 NM (approximately 7 seconds) after the descent point specified for the constant angle approach path. The average rate of descent was 1000 ft/min, increasing to 1700 ft/min. At 11:43 the Metro was over the FAF at an altitude of 2379 feet. The altitude at this stage should have been 2860 feet. The flight descended then through the segment minimum safe altitude of 2,060 ft. It continued to descend until it flew into the side of a heavily timbered ridge in the Iron Range National Park. The height of the initial impact with trees was 1,210 ft, which was about 90 ft below the crest of the ridge.

Probable Cause:

CONTRIBUTING FACTORS RELATING TO OCCURRENCE EVENTS AND INDIVIDUAL ACTIONS- The crew commenced the Lockhart River Runway 12 RNAV (GNSS) approach, even though the crew were aware that the copilot did not have the appropriate endorsement and had limited experience to conduct this type of instrument approach.- The descent speeds, approach speeds and rate of descent were greater than those specified for the aircraft in the Transair Operations Manual. The speeds and rate of descent also exceeded those appropriate for establishing a stabilised approach.- During the approach, the aircraft descended below the segment minimum safe altitude for the aircraft's position on the approach.- The aircraft's high rate of descent, and the descent below the segment minimum safe altitude, were not detected and/or corrected by the crew before the aircraft collided with terrain.- The accident was almost certainly the result of controlled flight into terrain.

CONTRIBUTING FACTORS RELATING TO LOCAL CONDITIONS- The crew probably experienced a very high workload during the approach.- The crew probably lost situational awareness about the aircraft's position along the approach.- The pilot in command had a previous history of conducting RNAV (GNSS) approaches with crew without appropriate endorsements, and operating the aircraft at speeds higher than those specified in the Transair Operations Manual.- The Lockhart River Runway 12 RNAV (GNSS) approach probably created higher pilot workload and reduced position situational awareness for the crew compared with most other instrument approaches. This was due to the lack of distance referencing to the missed approach point throughout the approach, and the longer than optimum final approach segment with three altitude limiting steps.- The copilot had no formal training and limited experience to act effectively as a crew member during a Lockhart River Runway 12 RNAV (GNSS) approach.

CONTRIBUTING FACTORS RELATING TO TRANSAIR PROCESSES- Transair's flight crew training program had significant limitations, such as superficial or incomplete ground-based instruction during endorsement training, no formal training for new pilots in the operational use of GPS, no structured training on minimising the risk of controlled flight into terrain, and no structured training in crew resource management and operating effectively in a multi-crew environment. (Safety Issue)- Transair's processes for supervising the standard of flight operations at the Cairns base had significant limitations, such as not using an independent approved check pilot to review operations, reliance on passive measures to detect problems, and no defined processes for selecting and monitoring the performance of the base manager. (Safety Issue)- Transair's standard operating procedures for conducting instrument approaches had significant limitations, such as not providing clear guidance on approach speeds, not providing guidance for when to select aircraft configuration changes during an approach, no clear criteria for a stabilised approach, and no standardised phraseology for challenging safety-critical decisions and actions by other crew members. (Safety Issue)- Transair had not installed a terrain awareness and warning system, such as an enhanced ground proximity warning system, in VH-TFU.- Transair's organisational structure, and the limited responsibilities given to non-management personnel, resulted in high work demands on the chief pilot. It also resulted in a lack of independent evaluation of training and checking, and created disincentives and restricted opportunities within Transair to report safety concerns with management decision making. (Safety Issue)- Transair did not have a structured process for proactively managing safetyrelated risks associated with its flight operations. (Safety Issue)- Transair's chief pilot did not demonstrate a high level of commitment to safety. (Safety Issue)

CONTRIBUTING FACTORS RELATING TO THE CIVIL AVIATION SAFETY AUTHORITY'S PROCESSES- CASA did not provide sufficient guidance to its inspectors to enable them to effectively and consistently evaluate several key aspects of operator management systems. These aspects included evaluating organisational structure and staff resources, evaluating the suitability of key personnel, evaluating organisational change, and evaluating risk management processes. (Safety Issue)- CASA did not require operators to conduct structured and/or comprehensive risk assessments, or conduct such assessments itself, when evaluating applications for the initial issue or subsequent variation of an Air Operator's Certificate. (Safety Issue)

OTHER FACTORS RELATING TO LOCAL CONDITIONS- There was a significant potential for crew resource management problems within the crew in high workload situations, given that there was a high trans-cockpit authority gradient and neither pilot had previously demonstrated a high level of crew resource management skills.- The pilots' endorsements, clearance to line operations, and route checks did not meet all the relevant regulatory and operations manual requirements to conduct RPT flights on the Metro aircraft. - Some cockpit displays and annunciators relevant to conducting an instrument approach were in a sub-optimal position in VH-TFU for useability or attracting the attention of both pilots.

OTHER FACTORS RELATING TO INSTRUMENT APPROACHES - Based on the available evidence, the Lockhart River Runway 12 RNAV (GNSS) approach design resulted in mode 2A ground proximity warning system alerts and warnings when flown on the recommended profile or at the segment minimum safe altitudes. (Safety Issue) - The Australian convention for waypoint names in RNAV (GNSS) approaches did not maximise the ability to discriminate between waypoint names on the aircraft global positioning system display and/or on the approach chart. (Safety Issue) - There were several design aspects of the Jeppesen RNAV (GNSS) approach charts that could lead to pilot confusion or reduction in situational awareness. These included limited reference regarding the 'distance to run' to the missed approach point, mismatches in the vertical alignment of the plan-view and profile-view on charts such as that for the Lockhart River runway 12 approach, use of the same font size and type for waypoint names and 'NM' [nautical miles], and not depicting the offset in degrees between the final approach track and the runway centreline. (Safety Issue) - Jeppesen instrument approach charts depicted coloured contours on the plan-view of approach charts based on the maximum height of terrain relative to the airfield only, rather than also considering terrain that increases the final approach or missed approach procedure gradient to be steeper than the optimum. Jeppesen instrument approach charts did not depict the terrain profile on the profile-view although the segment minimum safe altitudes were depicted. (Safety Issue) - Airservices Australia's instrument approach charts did not depict the terrain contours on the plan-view. They also did not depict the terrain profile on the profile-view, although the segment minimum safe altitudes were depicted. (Safety Issue)

OTHER FACTORS RELATING TO TRANSAIR PROCESSES - Transair's flight crew proficiency checking program had significant limitations, such as the frequency of proficiency checks and the lack of appropriate approvals of many of the pilots conducting proficiency checks. (Safety Issue) - The Transair Operations Manual was distributed to company pilots in a difficult to use electronic format, resulting in pilots minimising use of the manual. (Safety Issue) Other factors relating to regulatory requirements and guidance - Although CASA released a discussion paper in 2000, and further development had occurred since then, there was no regulatory requirement for initial or recurrent crew resource management training for RPT operators. (Safety Issue) - There was no regulatory requirement for flight crew undergoing a type rating on a multi-crew aircraft to be trained in procedures for crew incapacitation and crew coordination, including allocation of pilot tasks, crew cooperation and use of checklists. This was required by ICAO Annex 1 to which Australia had notified a difference. (Safety Issue) - The regulatory requirements concerning crew qualifications during the conduct of instrument approaches in a multi-crew RPT operation was potentially ambiguous as to whether all crew members were required to be qualified to conduct the type of approach being carried out. (Safety Issue) - CASA's guidance material provided to operators about the structure and content of an operations manual was not as comprehensive as that provided by ICAO in areas such as multi-crew procedures and stabilised approach criteria. (Safety Issue) - Although CASA released a discussion paper in 2000, and further development and publicity had occurred since then, there was no regulatory requirement for RPT operators to have a safety management system. (Safety Issue) - There was no regulatory requirement for instrument approach charts to include coloured contours to depict terrain. This was required by a standard in ICAO Annex 4 in certain situations. Australia had not notified a difference to the standard. (Safety Issue) - There was no regulatory requirement for multi-crew RPT aircraft to be fitted with a serviceable autopilot. (Safety Issue)

OTHER FACTORS RELATING TO CASA PROCESSES - CASA's oversight of Transair, in relation to the approval of Air Operator's Certificate variations and the conduct of surveillance, was sometimes inconsistent with CASA's policies, procedures and guidelines. - CASA did not have a systematic process for determining the relative risk levels of airline operators. (Safety Issue) - CASA's process for evaluating an operations manual did not consider the useability of the manual, particularly manuals in electronic format. (Safety Issue) - CASA's process for accepting an instrument approach did not involve a systematic risk assessment of pilot workload and other potential hazards, including activation of a ground proximity warning system. (Safety Issue) Other key findings An 'other key finding' is defined as any finding, other than that associated with safety factors, considered important to include in an investigation report. Such findings may resolve ambiguity or controversy, describe possible scenarios or safety factors when firm safety factor findings were not able to be made, or note events or conditions which 'saved the day' or played an important role in reducing the risk associated with an occurrence. - It was very likely that both crew members were using RNAV (GNSS) approach charts produced by Jeppesen. - The cockpit voice recorder did not function as intended due to an internal fault that had developed sometime before the accident flight and that was not discovered or diagnosed by flight crew or maintenance personnel. - There was no evidence to indicate that the GPWS did not function as designed. - There would have been insufficient time for the crew to effectively respond to the GPWS alert and warnings that were probably annunciated during the final 5 seconds prior to impact with terrain.

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority review and clarify the legal requirements concerning the qualifications for two-crew (pilot) operation during the conduct of instrument approaches in air transport operations. The review should assess the safety benefit arising from ensuring that when an instrument approach is conducted in an aircraft required to be operated by a two-person flight crew, both flight crew members are qualified to conduct the type of approach being carried out.

Issued: 24-JAN-2006

To: CASA

R20060003

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority review the adequacy of current legislation and regulations: to assess the safety benefit that could be achieved from the fitment of a serviceable autopilot to all aircraft currently on the Australian civil aircraft register, engaged on scheduled air transport operations with a view to ensuring that all aircraft placed on the Australian civil aircraft register after a specified date and intended to be engaged on scheduled air transport operations are equipped with a serviceable autopilot.

Issued: 10-FEB-2006

To: CASA

R20060005

The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority review the maintenance requirements for cockpit voice recording systems and flight data recording systems against international standards such as EUROCAE ED-112 and ICAO Annex 6 with the aim of improving their reliability and increasing the availability of data to investigators. (Closed - Partial Action)

Issued: 10-FEB-2006

To:

R20060006

The Australian Transport Safety Bureau recommends that the Department of Transport and Regional Services, with the assistance of the Civil Aviation Safety Authority, pursues further the development of proposals to amend the provisions of Part IIIB of the Civil Aviation Act 1988. While recognising the need to have protections to prevent inappropriate disclosure and use of Cockpit Voice Recorder information, the proposals to amend the CA Act should take into account the need to enable approved maintenance organisations to replay in-flight Cockpit Voice Recorder data for legitimate maintenance and testing purposes. (Closed - Action Taken)

Issued: 04-APR-2007

To: CASA

R20070002

CASA did not provide sufficient guidance to its inspectors to enable them to effectively and consistently evaluate several key aspects of operator management systems. These aspects included evaluating organisational structure and staff resources, evaluating the suitability of key personnel, evaluating organisational change, and evaluating risk management processes.
The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority undertake further work to address this safety issue. (Closed - Action Taken)

Issued: 04-APR-2007

To: CASA

R20070003

CASA did not require operators to conduct structured and/or comprehensive risk assessments, or conduct such assessments itself, when evaluating applications for the initial issue or subsequent variation of an Air Operator\'s Certificate.
The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority undertake further work to address this safety issue. (Closed - Action Taken)

Issued: 04-APR-2007

To: CASA

R20070004

CASA did not have a systematic process for determining the relative risk levels of airline operators.
This issue was discussed in the analysis section of the draft report but was not listed as a safety issue. However, it has now been included as a safety issue following assessment of comments on the draft report.
The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority address this safety issue. (Closed - Partial Action)

Issued: 04-APR-2007

To: CASA

R20070005

CASA\'s process for accepting an instrument approach did not involve a systematic risk assessment of pilot workload and other potential hazards, including activation of a ground proximity warning system.
The ATSB recommends that the Civil Aviation Safety Authority address this safety issue. (Closed - Action Taken)

Issued: 04-APR-2007

To: CASA

R20070006

CASA\'s guidance material provided to operators about the structure and content of an operations manual was not as comprehensive as that provided by ICAO in areas such as multi-crew procedures and stabilised approach criteria. The ATSB recommends that the Civil Aviation Safety Authority address this safety issue. (Closed - Accepted)

Issued: 04-APR-2007

To: CASA

R20070007

There was no regulatory requirement for instrument approach charts to include coloured contours to depict terrain. This was required by a standard in ICAO Annex 4 in certain situations. Australia had not notified a difference to the standard.
The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority address this safety issue. (Closed - Action Taken)

Issued: 04-APR-2007

To: CASA

R20070008

Based on the available evidence, the Lockhart River Runway 12 RNAV (GNSS) approach design resulted in mode 2A ground proximity warning system alerts and warnings when flown on the recommended profile or at the segment minimum safe altitudes.
This safety issue was not listed in the draft report but was identified during assessment of comments on the draft report. CASA was formally advised of this safety issue on 20 March 2007.
The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority address this safety issue. (Closed - Action Taken)

Issued: 04-APR-2007

To: Jeppesen Sanderson

R20070009

Based on the available evidence, the Lockhart River Runway 12 RNAV (GNSS) approach design resulted in mode 2A ground proximity warning system alerts and warnings when flown on the recommended profile or at the segment minimum safe altitudes.
This safety issue was not listed in the draft report but was identified during assessment of comments on the draft report. CASA was formally advised of this safety issue on 20 March 2007.
The Australian Transport Safety Bureau recommends that the Civil Aviation Safety Authority address this safety issue. (Closed - Partial Action)

Issued: 04-APR-2007

To: Jeppesen Sanderson

R20070010

Jeppesen instrument approach charts depicted coloured contours on the plan-view of approach charts based on the maximum height of terrain relative to the airfield only, rather than also considering terrain that increases the final approach or missed approach procedure gradient to be steeper than the optimum. Jeppesen instrument approach charts did not depict the terrain profile on the profile-view although the segment minimum safe altitudes were depicted.
The Australian Transport Safety Bureau recommends that Jeppesen Sanderson Inc. address this safety issue. (Closed - Action Taken)

Issued: 04-APR-2007

To: Airservices Australia

R20070011

Airservices Australia\'s instrument approach charts did not depict the terrain contours on the plan-view. They also did not depict the terrain profile on the profile-view, although the segment minimum safe altitudes were depicted.
The Australian Transport Safety Bureau recommends that Airservices Australia address this safety issue. (Closed - Action Taken)

This information is not presented as the Flight Safety Foundation or the Aviation Safety Networkís opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.